Darren Trewin
PFD Report
All Responded
Ref: 2018-0138
All 1 response received
· Deadline: 4 Jul 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
4 Jul 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1) The drain in the central reservation was partially blocked with detritus washed from the road_ drain therefore could not take all the water from the heavy rain showers resulting in the water cascading across the carriageway contributing to the collision. Highways engineers who attended the Inquest were of the view that the grating on the drain should be changed to capture more water and the drains inspected more frequently and an additional drain, located above the drain that blocked should be created to assist with the capture of excess water from rain (2) To consider extending the barrier on the nearside of the carriageway to a before the point of impact would possibly have prevented Mr Trewin's car from leaving the carriageway and entering the woods longer barrier at this point; where the ground drops away to a much lower level below the carriageway, could improve safety for all drivers using the A30 at this point
Responses
Response received
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REGULATION 28 REPORT TO PREVENTFUTURE DEATHS THIS RESPONSE IS BEING SENT TO: The Assistant Coroner for Exeter and Greater Devon, Mr John Tomalin of Devon County Hall, Topsham Road; Exeter, DEVON EXz 4QD in response to a 'Regulation 28 Report to Prevent Future Deaths' following an inquest hearing into the death of Darren TREWIN that concluded on 25 April 2018_ HIGHWAYS ENGLAND 1 am Mr Andrew Page-Dove, South West Regional Director for Highways England Company Limited of Bridge House, 1 Walnut Tree Close; Guildford, SURREY, GU1 CORONERS MATTERS OF CONCERN The MATTERS OF CONCERN were identified are as follows: The drain in the central reservation of the 430 Southbound near Sourton Cross was partially blocked with detritus washed from the road The drain could not take all the water from the rain showers resulting in the water cascading across the carriageway contributing to the collision; and
b. To consider extending the barrier on the nearside of the carriageway to a point before the of impact where the ground drops away to a much lower level below the carriageway would possibly have prevented Mr Trewin's car from leaving the carriageway. DETATLS OF ACTION TAKEN Drainage: Immediately after the collision we provided temporary mitigation by placing sand on the downhill side ofthe gully grating to ensure that any excess flow of rainwater was directed into the gully and away from the carriageway The location was flagged and recorded as a flooding 'hotspot' immediately after the incident This ensures that the location is subjected to a weekly inspection by Highways England (HE) inspectors; If the inspector sees any material that may have the potential to compromise the gully operation it is removed at the time if possible Ifthe matter cannot be dealt with by HE inspectors at the time, OuI service provider (Ringway Infrastructure Services Limited) is called in to undertake more substantial operations to ensure the gully operates as designed _ The time period for Iesponse from the service provider is dependent upon a combination ofthe nature ofthe problem; weather conditions at the time and the immediate weather forecast: An additional gully has been installed adjacent to the existing gully at the end of the drainage channel to increase the efficiency ofrainwater interception and prevent water from reaching the carriageway: This work was completed on 16 June 2018. This gully will be subject to the same maintenance regime as described above_
b. The vehicle restraint barrier is addressed at 4b. below DETAILS OF FURTHER ACTION PROPOSED Drainage: 4LZ heavy_ point bags point _
Afurther gully will be installed approximately 100 metres uphill of the end of the drainage channel referred to in point 3a. above: This will further increase surface water drainage capacity and reduce the amount of water 'reaching the lower gully: This piece of work is currently in the design process and will be constructed by the end of September 2018. A wider drainage study at the location (from the to the bottom of the hill) has commenced and is due for completion this financial year (2018/19). The study will require detailed modelling to determine if there is any other work that can be undertaken to further mitigate the risk of a similar collision b: Vehicle restraint barrier: A Road Restraint Risk Assessment Process (RRRAP) is to be undertaken in the vicinity of the existing vehicle restraint by the end of September 2018. This will inform the requirement for a vehicle restraint barrier at the location in line with current standards. Dependent upon the outcome; we will implement a scheme to introduce a vehicle restraint barrier that reflects the risk assessment findings_ TIMETABLE FORACTTON DATE ACTION 16-06-18 Install additional gully adjacent to existing gully 30-09-18 Install additional gully 1oom upstream of existing gully 30-09-18 Undertake Road Restraint Risk Assessment (RRRAP) 31-03-19 Complete a wider drainage study 31-03-19 Act upon the outcome ofthe RRRAP to include design, construction, and/ Or modification of the existing vehicle restraint barrier (ifappropriate) SAFETY OF ROAD USERS The safety of OUT road users is an imperative for our business in what we set out to achieve and a core value of our organisation in how we go about it. The action planned and underway is in this light to help to prevent future deaths at this location: Date: 21/ |t& Signed: Regional Director on behalf of Jim OSullivan existing` top
b. To consider extending the barrier on the nearside of the carriageway to a point before the of impact where the ground drops away to a much lower level below the carriageway would possibly have prevented Mr Trewin's car from leaving the carriageway. DETATLS OF ACTION TAKEN Drainage: Immediately after the collision we provided temporary mitigation by placing sand on the downhill side ofthe gully grating to ensure that any excess flow of rainwater was directed into the gully and away from the carriageway The location was flagged and recorded as a flooding 'hotspot' immediately after the incident This ensures that the location is subjected to a weekly inspection by Highways England (HE) inspectors; If the inspector sees any material that may have the potential to compromise the gully operation it is removed at the time if possible Ifthe matter cannot be dealt with by HE inspectors at the time, OuI service provider (Ringway Infrastructure Services Limited) is called in to undertake more substantial operations to ensure the gully operates as designed _ The time period for Iesponse from the service provider is dependent upon a combination ofthe nature ofthe problem; weather conditions at the time and the immediate weather forecast: An additional gully has been installed adjacent to the existing gully at the end of the drainage channel to increase the efficiency ofrainwater interception and prevent water from reaching the carriageway: This work was completed on 16 June 2018. This gully will be subject to the same maintenance regime as described above_
b. The vehicle restraint barrier is addressed at 4b. below DETAILS OF FURTHER ACTION PROPOSED Drainage: 4LZ heavy_ point bags point _
Afurther gully will be installed approximately 100 metres uphill of the end of the drainage channel referred to in point 3a. above: This will further increase surface water drainage capacity and reduce the amount of water 'reaching the lower gully: This piece of work is currently in the design process and will be constructed by the end of September 2018. A wider drainage study at the location (from the to the bottom of the hill) has commenced and is due for completion this financial year (2018/19). The study will require detailed modelling to determine if there is any other work that can be undertaken to further mitigate the risk of a similar collision b: Vehicle restraint barrier: A Road Restraint Risk Assessment Process (RRRAP) is to be undertaken in the vicinity of the existing vehicle restraint by the end of September 2018. This will inform the requirement for a vehicle restraint barrier at the location in line with current standards. Dependent upon the outcome; we will implement a scheme to introduce a vehicle restraint barrier that reflects the risk assessment findings_ TIMETABLE FORACTTON DATE ACTION 16-06-18 Install additional gully adjacent to existing gully 30-09-18 Install additional gully 1oom upstream of existing gully 30-09-18 Undertake Road Restraint Risk Assessment (RRRAP) 31-03-19 Complete a wider drainage study 31-03-19 Act upon the outcome ofthe RRRAP to include design, construction, and/ Or modification of the existing vehicle restraint barrier (ifappropriate) SAFETY OF ROAD USERS The safety of OUT road users is an imperative for our business in what we set out to achieve and a core value of our organisation in how we go about it. The action planned and underway is in this light to help to prevent future deaths at this location: Date: 21/ |t& Signed: Regional Director on behalf of Jim OSullivan existing` top
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action_
Report Sections
Investigation and Inquest
On the gth February 2017 commenced an investigation into the death of Darren Richard Trewin, age 49 years_ The investigation concluded at the end of the Inquest on the 251h April 2018,the conclusion of the Inquest was Mr Trewin died as a result of a Road Traffic Collision contributed to by water flowing across the A30 carriageway from a blocked drain on the central reservation. The Pathologist gave the medical cause of death as "1(a) Head Injuries with Airway Compromise
Circumstances of the Death
On the 31st January 2017 Mr Trewin was driving a Mercedes SLK motor vehicle belonging to his partner who was his passenger. He was drivving along the A30 Southbound when approximately % mile west of Sourton Cross near Okehampton, Devon. The car ran into a stream of water running from right to left across the carriageway from a partially blocked drain on the central reservation. This initial loss of traction, together with driver input to control the car resulted in the car leaving the carriageway at a point when it collided with the concrete anchor at the start of a barrier on the nearside of lane one, resulting in the car turning over landing upside down in woodland where the branch of a tree entered the cabin causing fatal injuries to Mr Trewin.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.